mosquito bites because they moved from non-malarial places in Central Eastern Burma to malarial place in the borderland. They came to the borderland without knowing that malaria is endemic. Some had never heard about the disease (Personal conversation with Dr. Francois Nosten in Mae Sot, March 11, 2011).
Dr. Nosten’s narrative gives us a glimpse into why some Karen migrant patients at the SMRU do not seem to know about malaria even though they came to seek treatment for their fever at malaria research clinics. People who have spent some time in the Thai-Burma
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borderland have experienced malaria several times. However, despite their sequential malaria experiences, almost half of the patients with whom I conducted interviews (71 individuals in total) did not give me a clear answer (bite by malaria infected mosquito) regarding how they had contracted malaria parasites. Moreover, approximately half of all the patients I
interviewed provided pluralistic ideas of malaria causality. This is how I learned that a quantitative survey method on Karen understandings of malaria may not provide a clear picture of the local perceptions of malaria symptoms and the complexity of malaria causality. This chapter begins with several illness accounts of undocumented Karen migrant patients at SMRU clinics, and their understandings of the body and illness, particularly malaria.
Like many other hill minority groups in Thailand and Burma, the Karen traditionally have animistic beliefs and practices, with the spirituality of the Karen permeating every aspect of their life (Buadaeng 2007; Hayami 2004; Keyes 1994; Rev. Loo Shwe 2006). Sirisai pointed out that the Karen in northern Thailand recognize that there are 33 spirits called “ke?la” embedded in the body organs and they are the vital forces of the body (Sirisai 1993:129). It is believed that people become sick when the ke?la is attacked by evil spirits and leaves the body. Sirisai (1993) articulated the Karen cultural perceptions of malaria in which traditional healers rationalized the illness with regards to the specific times and locations. According to Sirisai’s study in a Karen village near where I conducted fieldwork, Karen understandings of malaria is caused by the attack of spirits which have inhabited certain places at certain times, generally close to water sites (ibid.:130). Having these explanations in mind, Sirisai’s explanation of the Karen’s close relation to ecological environment and its implication to their cultural perception of malaria provides a unique cultural ecological perspective.
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However, what Sirisai did not mention in her short report is the fact that Karen people have an extensive lexicon to describe their bodily symptoms related to the imbalance of the internal body, cultural concepts of hot/cold, and the existence of air/wind in internal body, which are important to understand the perceptions of malaria. Previous studies on local perceptions of the body and illness were often examined within linguistic investigation and ethnomedical concepts of the body and illness/health. There are some analogies between linguistic explanations of illness causality or disease agent and cultural perceptions of body symptoms.
In the Karen terms, malaria is referred to as “malaria illness” and people relate the illness to mosquitos. Malaria illness is called tanyaa-ghoo-kha or pajyo-kha in Sgaw Karen, and kijyo kha in Pwo Karen. Mosquito is referred to pajyo in Sgaw Karen and kijyo in Pwo Karen, respectively. Thus, both pajyo kha and kijyo kha mean ‘mosquito infection.’ While the terms of pajyo kha and kijyo kha show that the symptoms are associated with mosquito, the term tanyaa-ghoo-kha is somewhat ambivalent, as it implies other infectious diseases that also cause fever. For example, Sgaw Karen patients used tanyaa-ghoo-kha to describe
various symptoms look like malaria, such as common flu (‘To’kwe’69), and they viewed tanyaa-ghoo-kha as caused by various factors, including mosquito. Such factors include: imbalance of the body in contacting with nature (i.e., cold water, wind, hot sun, fire frame), one’s past activities at particular time and space, and one’s feeling of belonging to particular ethnicity, citizenship, and place.
The following malaria narrative is a Karen patient’s experience of the illness. The
69Some patients used To’kwe to refer to dengue fever. One female Sgaw Karen medical staff at SMRU said that because there was no Karen term to describe dengue fever, which was an emerging disease in the area, Karen migrants used To’kwe to refer to both common flu and dengue fever.
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patient’s illness account articulates her bodily experience as abnormal pain of body parts, which were objectified through pain. ‘Tsa Mu’ was a 46-year-old female migrant patient who had had fifteen pregnancies but only seven survived. My research assistant asked about her reason of coming to the clinic.
I have been having a fever for four days. The clinic staff said it was not the severe one. I think my fever has something to do with my heart or my liver. My heart is in pain, very painful (touching her chest by her hand). I took medicine, but I am still in pain. I cannot breathe. My headache started at the end of the Songkran festival (around mid-April in 2012). I had a headache [pointed to her head] but no fever. I have burning stomach pains after eating and drinking water and it affected my heart. Now I am taking medicine to treat burning pain [squeezed her eyes tightly]. Tharamu (female practitioner) examined me. I told her that I had trouble breathing and I felt burning heart pains. I cannot sleep. The first two days I took malarial medicine in the hospital, and the medicine made me feel dizzy. I don’t want to open my eyes even at this moment. I want to close my eyes but I cannot sleep even I close my eyes. Also, I don’t feel hungry so I am chewing betel nut, because I want to vomit [pause]. A while ago, I started feeling heart pain and tharamu asked me if I was breathing okay. No! I said. I felt my heart was beating fast, like my heart was jumping and I felt
exhausted.70
Tsa Mu did not tell us that she was diagnosed malaria positive at first. Instead, she detailed her experiences of various bodily discomforts. From this account, it was clear that the illness overwhelmed her with its symptoms. Her following story further suggested that the illness caused her disengagement in social interactions with people around her.
As soon as I arrived home from work in the khgu (rice field), I lay on my bed because I did not have strength to talk to people even when they were talking to me. I did not respond and remained silent. First it (pain) started with my heart. It was a piercing pain here and there [moved her finger from heart to limbs]. When I had malaria before, I used to feel pain in my hands and legs, and test results showed that it was malaria. [pause] I never had malaria when I was at Ler Le village. (Researcher: “In total, how many times did you have malaria after you came to Boh Deh village?”) Plenty! I also have had the severe one; how many times, I don’t remember. But I keep all lemas (her personal medical record books) at home. I have four lemas completely full! Including this one, altogether five! The first year I came here, I remember that, hmm… I rested only one month and malaria came back again, and after that it was
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constant. This time I got malaria and the malaria illness (Tanyaa-ghoo-kha) is different. In the past, I had a severe headache. It was very painful like something pinching my brain and burning pain in my eyes. This time, my heart is in pain and I am still not feeling well. I take medicine and it helps little bit, but the pain does not go away… It’s like, when you have malaria, you cannot live peacefully, you do not feel well, you feel your heart and liver are burning, you feel really really unwell! Even though you want to vomit, nothing comes out. You don’t have an appetite… When you have fever, you cannot sleep. I rolled on the floor and did not let anyone sleep in the same space, because I felt feverish and wanted to bathe again and again.
Tsa Mu articulated her illness history by referencing her accumulating patient record books, which listed her past malaria episodes and medics’ diagnoses. By collecting memories of malaria episode(s) within her domestic context and recalling various symptoms by
internalizing pains into the mind and body parts, her illness accounts described how malaria transformed the way she viewed her body suffering. Through her accounts of various pains on her body, she demonstrated that her body was in crisis.
To discuss the bodily pain, I attempt to utilize phenomenological approaches. Thomas Csordas argued that whether the pain really exists or not in the mind was not a proper
question, because the pain experience is internalized in one’s mind through the body (Csordas 1990; Jackson 2000). Tsa Mu’s narratives contain her experiences of mind
suffering (“when you have malaria, you cannot live peacefully”) as well as physical pain. Her emotional accounts show that the illness equally burdened her body and mind. She described the accumulated lema as evidence of her lived experience and strongly sensed that she had been sick for a long time due to malaria (and possibly by other illnesses), as if her
consequential malaria episodes were almost like chronic disease. The next section describes the multiplicity of understandings of malaria among undocumented Karen migrants.
Medical anthropologist Arthur Kleinman (1980) claimed that Chinese traditional doctors understood the human body and pathological changes were in a continuous process
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of adaptation to the natural environment. Drawing on the Karen migrant patients’ accounts on the malaria experience, I relate the Karen migrants’ perceptions of the illness and their cosmic views of one’s body and health to the environmental elements to Kleinman’s cultural interpretive approach.
Kyaw Pyu was a 45-year-old, male Sgaw Karen patient, who had been living in Thee Kow Htoo village along the border for twelve years. He came to the WP clinic by himself around one o’clock in the afternoon when most out patients had already left the clinic. He was in a hurry, uncomfortably sitting on a chair alone in a spacious empty waiting area. I saw that his malaria rapid checker showed that he was positive with malaria P. vivax. Both of Kyaw Pyu’s eyes had cataracts and were paralyzed. As I approached him with my notepad, he seemed a little nervous. I started asking what brought him to the clinic. After a few
moments of hesitation, he started explaining to me that he came for a blood check because he was suspected of contracting malaria. He said:
Kyaw Pyu (KP): I came here for my kotakichaa (headache). I feel like tanyaa-ghoo (malaria infection), but not sure.
Asami (Asami): Did you have the same health problem before?
KP: Yes. I feel taku? (fever), and tanoaa (chill) on and off for long time. I feel like it has been more than ten years71. Now I also feel takii (body ache).
Asami: Do you know what caused your health problem? KP: I feel like it is tanyaa-ghoo kha (I get malaria) Asami: Do you know how people get tanyaa-ghoo-ka?
71Earlier, Kyaw Pyu described that he had the symptoms for seven or eight years and later he changed it to ten years. This changing numbers, giving approximate one’s age are very common among the patients at the clinic. I think in this case, he was trying to stress the fact that he had been ill for such long time.
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KP: I think it comes from pajyo (mosquito). If you get bites from pajyo, you get ahka (germ). It starts like this. There are various kinds of symptoms related to tanyaa-ghoo kha. Some get fever, headache, cold, shivering, like this, dadadadada [shook his body quickly]. Then we know it is tanyaa-ghoo-kha. There are two types in symptoms of tanyaa-ghoo-kha. One type is headache, fever, and another type is chill and shivering. Some feel heat deep inside of their eyes. Some others feel cold all the time.
Kyaw Pyu provided an extensive information of what symptoms he thought that were related to malaria. Clearly, he associated malaria with mosquito bites. However, from his answer, it was not clear, then how one could prevent malaria.
Asami: To avoid tanyaa ghoo kha, what do you do? How do you prevent getting sick by tanyaa ghoo kha?
KP: When I am at home and feel cold, I take one or two tablets of para (paracetamol) per day.
Asami: Is there any way you could avoid tanyaa ghoo kha?
Research Assistant: Now you have no malaria and you do not want to get it again, how do you prevent malaria?
KP: Now I do not come again because I already came regularly for follow up.
The conversation with Kyaw Pu shows that there were discrepancies between the researcher’s intention and the informant’s information. When I asked how to prevent malaria, Kyaw Pyu said that he would only take paracetamol, which is a typical pharmaceutical drug to relieve fever and pain available in Thailand and Burma. To clarify my question, my research assistant repeated the question by changing words. However, Kyaw Pyu did not directly answer the question. Thus, I asked him again how other people in his village knew if they had malaria.
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clinical study would protect him from future malaria infection. In fact, his answer was not pointless at all. At clinics, health practitioners explained to patients that the clinical studies were good for them because it would prevent recurrence of malaria. A nurse at one of the SMRU clinics told me:
I tell patients that I, too, have had malaria before. But after I participated in a study, I have never had malaria again. Whenever I have disobedient patients, I tell them directly, if you want to go back and see your family again, you must follow what the staff tells you otherwise you will never reach to your village (and see your family again).72
Hla Htway shared his notions of malaria symptoms with what Kyaw Pyu listed. He also associated malaria with several common symptoms: body ache, recurring fever and chill, hot feeling from inside of the body. Hla Htway stated that tanyaa-ghoo-kha was related to mosquito bites. However, when I asked him how he got tanyaa-ghoo-kha in his case, he gave me a different response:
During the rainy season, water is not clean. I do not boil water. It is tanyaa-ghoo-kha, not pajyo-kha (mosquito-bite infection). I always know when I get tanyaa-ghoo-kha because I get body aches, fever, and sometimes my body gets swollen. I have the same symptoms every time. The heat comes from inside of my body. I have been living in my place for twelve years and I get one or two (episodes) every year.73
Hla Htway’s description of his tanyaa-ghoo-kha enacted a sense of normalcy of malaria as a common illness in villages along the border. Although he had heard that the illness was caused by mosquito bites and told me that tanyaa-ghoo-kha was associated with mosquito bites, he was not fully convinced with the biomedical explanatory model. From his
explanation, types of tanyaa-ghoo-kha were traced to places where migrant villagers had temporarily worked and lodged. The following account clarifies the idea of malaria
72 Interview with A female health worker, at one of the SMRU clinics, April 23, 2011. 73 Interview with Hla Htway, A male Sgaw Karen at Wang Pa clinic, October 21, 2012.
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Daw Aye Aye remembered a malaria situation in her village in Pa-an inside of the Karen State thirty years ago. Aye Aye was over 40 years old. She had been living in a Thai- side Wang Pa village for nearly twelve years. Her narrative provided Karen beliefs on malaria, which was embedded in their notions of imbalance of the body caused by the elements of natural environment.
In the village (in Burma), when people got malaria, fever went up and down, up and down. Not like here (in Thailand), when we get malaria, we have cold and chills. We feel our bodies are very icy cold, like when we take a very cold bath. Three or four people hold the patient and try to warm the person, but the person still feels cold and cannot stop shaking. When the fever goes down, it feels like winter season. At the beginning of winter, chilly wind blows and they know they can be sick. So they take medication (Burmese herbal medicine) before they get sick. Here (Thailand), usually it happens in the middle of winter. In Pa-an (Burma), it is early winter, when people go to the forest.74
Daw Aye Aye explained that villagers who have close contact with the natural environment would get malaria often. Asking what kind of contacts, she explained that it depended on one’s activities and where they had traveled. She identified that some Karen migrants who spent time in the jungle to do some activities would get malaria fever. Such activities include: logging, making charcoal, collecting bamboo shoots and wild fruits, and hunting wild animals. I asked her what other groups of people would get malaria in Burma. Daw Aye Aye explained:
Poor people. It started from children. Everyone who worked in the forest got malaria. When they got sick, they had never gone to the hospital. They stayed at home and took traditional medicine.
Clearly, these informants’ descriptions of malaria reflected the proxy of natural environment. All three, Kyaw Pyu, Hla Htway, and Daw Aye Aye had experienced malaria
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several times or at least they heard and knew about malaria as a common illness among villagers living along the border. Hla Htway recalled his activities ‘going into the forest’ and ‘drank stream water without treatment’ to interpret his illness causality even though he clearly suggested that malaria was caused by mosquito bites. Daw Aye Aye distinguished the more susceptible group in her old village by the economic status of people and their relative age.
Villagers came to suspect malaria case once they started showing symptoms, such as recurring fever and chill, body ache, hot feeling on the eyes and body aches. From these illness accounts, however, the causality of illness was not clearly linked with mosquito bites, even though they pointed out a mosquito-agent causality (pajyo kha or kijyo kha— mosquito parasite infection). There was no clear consensus among Karen migrant villagers whether it was caused solely by mosquito bites or not. When asked further, Karen patients at the clinics answered that their malaria was caused by combined factors, including individual
socioeconomic status, occupations, and nature-body equilibrium imbalance. In villages, people were afraid of taking Inglesi medicine—biomedical,
pharmaceutical drugs. As you know, poor villagers do not want to take medication, so people died. They stayed on the foot of the mountains. (Researcher: “Why the
villagers did not want to take Inglesi medicine?”) They were afraid of the medicine because they were not familiar with it. They’d never seen the medicine. That